Welcome to Cross-Canada Paediatric - Respiratory Residency Rounds
Page 1 / February 07


Sami Alhaider MD
Fellow Pediatric Respiratory Medicine
Alberta Children's Hospital
University of Calgary


A 5 year old boy presented to the emergency room complaining of increasing shortness of breath in association with abdominal distention for 4 days. He has trisomy 21 (Down syndrome), and was recently diagnosed to have acute lymphoplastic leukemia (ALL). He was on the induction phase of chemotherapy for the preceding three weeks. He was also "labeled" to have viral induced wheezing episodes with intermittent use of inhaled bronchodilator and corticosteroid.

Triage assessment documented intermittent grunting with nasal flaring, good breath sounds in both sides of the chest, tachypnia, transcutanous O2 saturation of 93% on room air, afebrile, normal pulse and blood pressure.

His old chart review showed a recent emergency room visit 2 days prior to this presentation because of similar but milder symptoms. He had been discharged with a prescription of salbutamol and fluticasone inhalers via a valved holding chamber.

There was no history of fever, vomiting, wheezing, or preceding common cold symptoms. There was history of mild dry cough, with no diurnal variability. He showed suppressed activity and appetite. He had no bowel motion for the last three days, with regular soft motion before this illness. There was no history of contact with sick people, however he was attending a day care centre. He was born at term.

The emergency physician examination documented the following: mild respiratory distress, tachypnia, but no grunting. He looked pale, and his hydration status was adequate, with normal activity. Ear, nose and throat examination was unremarkable. There was a decrease in breath sounds to left side of the chest. His abdomen was found to be distended but was soft with no tenderness or palpable mass.

An abdominal X-ray was obtained in emergency room.

Figure 1.

How would you interpret this X-ray?

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